1467446294 NPI number — PAMELA H MCKINLEY LISW

Table of content: PAMELA H MCKINLEY LISW (NPI 1467446294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467446294 NPI number — PAMELA H MCKINLEY LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKINLEY
Provider First Name:
PAMELA
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MASON
Provider Other First Name:
PAMELA
Provider Other Middle Name:
H
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467446294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
158 E MARKET ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SANDUSKY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44870-2509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-621-7333
Provider Business Mailing Address Fax Number:
419-621-7335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
158 E MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SANDUSKY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44870-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-621-7333
Provider Business Practice Location Address Fax Number:
419-621-7335
Provider Enumeration Date:
09/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I.0003573 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 067725 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000213566 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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